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History and clinical findings | A 57-year-old woman with a history of emphysematous COPD GOLD D and homozygotic alpha-1-antitrypsin deficiency presented with aggravated dyspnoea, presyncope and left thoracic chest pain. 12 years previously Stanford type B dissection had been conservatively treated. Examinations | Chest radiograph revealed extended infiltrates of the left lower lobe. Seen together with elevated inflammatory values and the patient´s hemodynamic instability it pointed at a pneumonia-driven septic shock. In view of a progressive respiratory insufficiency and an acute drop in haemoglobin computed tomography was performed. It showed rupture of an aneurysmatic left lower pulmonary artery with consecutive intraparenchymal bleeding. Treatment and course | Because of persistent bleeding and respiratory failure requiring invasive ventilation, thoracotomy was performed. Left lower pulmonary artery was sutured and left lower lobe resected. After initial postoperative stabilization bronchopleural fistula demanded re-thoracotomy and parenchymal lesions of left upper lobe were sutured. In consequence of progressive sepsis and manifest multiorgan failure patient died 15 days after initial surgical bleeding control. Conclusion | Though homozygotic alpha-1-antitrypsin deficiency is primarily associated with lung and liver disease, extrapulmonary and extrahepatic manifestation may occur. In view of consistent case reports and plausible pathogenetic mechanisms, vascular complications comprising arterial aneurysms and dissection due to compromised vascular integrity in alpha-1-antitrypsin deficient individuals is conceivable, but lacks scientific proof., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The repair of complicated abdominal hernias remains a challenging problem. The components separation technique introduced by Ramirez et al. is an increasingly popular method for autogenous reconstruction of the abdominal wall, especially in combination with epifascial mesh reinforcement., Patients and Methods: In a retrospective study carried out at a university hospital, 40 consecutive patients between 2002 and 2010 were analyzed., Results: Indications for abdominal reconstruction were fascial defects after secondary healed laparostoma in 22 patients (55%) and fascial defects combined with colostomy reversal after a Hartmann procedure in 10 patients (25%). A total of 9 wound infections (22.5%) occurred and 10 hernia recurrences (10/36 patients) were identified in the follow-up (mean 3.8 years, range 1-9 years). Reconstructions with mesh reinforcement resulted in a lower rate of recurrences (19% with mesh vs 40% without mesh)., Conclusions: The components separation technique, in combination with epifascial mesh reinforcement as appropriate, is the procedure of choice for most complicated abdominal wall hernias. Therefore, each visceral surgeon should be able to perform this method. Recurrence rates depend on the underlying disease of the patient and the complexity of the hernia.

Umbilical hernia repair is often accompanied by complications in patients with liver cirrhosis and ascites. In recent years we have been using the following concept for treating umbilical hernias in such patients: repair of the hernia by direct sutures and concomitant implantation of two large bore Robinson drainage tubes until the wound healing was completed within the next postoperative 10-14 days. During this time the reconstruction of the abdominal wall is in our opinion as robust that the ascites no longer represents a risk. Preconditions to perform this procedure were the best medicamentous treatment of ascites as ever possible and the perioperative administration of prophylactic antibiotics like gyrase inhibitors to avoid spontaneous bacterial peritonitis. Over a period of 10 years (01.01.1997-31.12.2006) we operated on 22 patients suffering from liver cirrhosis and ascites because of a complicated umbilical hernia (incarceration, irreponibility, skin ulceration, leackage of ascites). One group of patients (n=10) was treated by umbilical hernia repair with the concomitant implantation of two drainage tubes and the other group (n=12) by umbilical hernia repair without draining off the ascites. Morbidity and mortality were compared in both groups in a retrospective analysis. The postoperative morbidity could be reduced from 25% to 10% by using the drainage tubes as well as the rate of recurrent hernias in the drainage group. Due to these experiences we use the concept as standard in such patients and would like to recommend it further. However, we would like to initiate a prospective, randomized, at best multicenter trial for further validation.

History and Clinical Findings: A 58-years-old non-smoking woman presented at our Thoracic Centre with increasing exertional dyspnea and on examination was found to have wheezing and decreased breath sounds over the left lung., Investigations: Chest X-ray revealed an atelectasis of the left anterobasal lung segment. Computed tomography revealed a 3.5 cm mass at the left inferior lobe. Bronchioscopy showed a total occlusion of the segmental bronchus because of an endobronchial tumor. Histology of a biopsy showed the tumor to be a carcinoid. Staging by whole-body ocreotide scintigraphy showed no evidence of metastases., Treatment and Course: The patient recovered quickly from resection of the left inferior lobe and radical lymphadenectomy. Two years later, she has remained free of symptoms and without evidence of recurrence., Conclusions: Although rare (ca. 1.0 % of all primary lung tumors), the differential diagnosis of dyspnea and uniliteral wheezing should include a bronchial carcinoid. It is a potentially curable tumor, if detected and treated early. An interdisciplinary approach is pivotal to its perioperative management.

Thymus surgery was initially dominated by the erroneous interpretation of the organs' pathogenicity and associated thymus diseases. Misleadingly, the thymus gland was made responsible for dyspnoea in children and a transcervical ektropexia was performed in a child suffering from dyspnoea in 1896. After F. Sauerbruch's thymectomy in a patient with myasthenia gravis syndrome (MG), A. Blalock established thymectomy in the 1940s for the treatment of MG. At the same time, the drug treatment initiated by M.B. Walker increased in significance. Despite progress in surgical techniques and the molecular understanding of MG pathogenesis, randomized controlled trials, which would increase the evidence for surgical access and indications for surgery compared to immunosuppressive treatment in MG, are lacking.

We present a 78-year-old female who had undergone rectal excision due to Crohn's disease of the rectum with loss of fecal continence. This led to a chronic perineal sinus and vaginal fistula which was closed with a Martius procedure using a bulbocavernosus fat flap. The sinus healed uneventfully after 4 weeks. In our opinion, the gracilis muscle was too large for this defect. We suggest use of this flap in female patients with small persistent perineal sinuses.

Unlabelled: We performed a retrospective analysis in patients after operative therapy of Crohn's disease in our institution., Patients and Methods: 81 patients that underwent surgery from 1990-1995 were analysed retrospectively. The follow up period in these patients was 42 months., Results: In 81 patients a total of 88 operations were performed. 56 patients were operated for the first time. The average patient's age was 35 years (range 14-76 years). Crohn's disease was located predominantly in the area of the ileocoecal valve. The most frequent operation was the ileocoecal resection. The prevalent operative indication in patients with small intestine Cohn's disease was the obstruction, in small intestine and colon manifestation the fistula. Complications in the early postoperative course appeared in 14 % of the patients. Postoperative mortality was 1.1 %. In a postoperative observation period of 3.5 years 3 of 57 patients (5 %) had to undergo surgery again, due to recurrence. Altogether 25 of 81 (31 %) patients revealed a recurrence., Conclusions: The surgical therapy of Crohn's disease can be performed safely and provides long-term recurrence and complaint free periods.

Objective: In the age of endoscopic papillotomy (EPT) the operative revision of the bile duct needs to be used stringently and interventional therapeutic options have to be considered primarily in the treatment of gallbladder and bile duct stone disease., Patients and Methods: 70 patients treated by choledochus revision for cholecysto- and choledocholithiasis in our department between 1988-1999 were analyzed retrospectively for indication and results., Results: ERCPs were performed in only 24 patients. In 17 patients no endoscopic papillotomy could be accomplished due to a former operation (Billroth II or Whipple-OP). 70 patients underwent a surgical bile duct exploration with insertion of a T-drainage. The postoperative surgical complication rate amounted to 36%. The most frequent complications after revision of the common bile duct were edematous pancreatitis as well as bile duct fistula. 37 of 70 patients could be reexamined 4-48 months postoperatively. A pancreatitis or stenosis of papilla Vateri were not seen in these patients. In the sonography the common bile duct was inconspicuous., Conclusions: In the therapy of bile duct stones the therapeutic splitting has become generally accepted. The patients should be submitted to a ERCP with EPT and subsequent laparoscopic cholecystectomy. Surgical revision of the common bile duct nevertheless remains an important tool in the therapy of choledocholithiasis.

We report the case of a 41-year old man, who developed leftsided and later rightsided inguinal pain radiating to the scrotum within three months. There was also sensory disturbance in the supply area of the left ilioinguinal nerve. No surgical procedures in the inguinal region had been done, so that we supposed an idiopathic entrapment neuropathy of the ilioinguinal nerve. Infiltration with local anesthetics resolved the complaints on the left side completely. On the right side neurolysis was necessary, to ablate symptoms. The entrapment neuropathy of the ilioinguinal nerve--often called ilioinguinal-syndrome--is a relevant differential diagnosis of inguinal pain. Anatomy, pathology, clinical presentation and therapy of this syndrome are discussed in the article. Knowledge of this syndrome prevents unnecessary investigation.

Anal canal stenosis with alteration of the sensoric continence or mucosal ectropion may occur after anorectal operations. Island flaps with perianal skin or the VY-anoplasty are simple plastic methods to reconstruct the anorectal region and cure patients--who often have suffered for a long time--from anal strictures or mucosal ectropion. In the period from 1994-1998 we reconstructed the anodermal region of seven patients using one of the above mentioned anorectal plastic procedures. Three patients complained of an anal stenosis and one patient suffered from an ectropion of the rectal mucosa after an improperly performed Whitehead hemorrhoidectomy. Three patients had a sensomotoric incontinence twice due to a congenital anal atresia and in one case caused by an accident. All patients were highly pleased after the operation--no complication occurred.

Introduction: The extremely rare but life-threatening hypercalcemic crisis is caused by an exacerbation of a chronic hyperparathyroidism. The etiologic reasons for this exacerbation are conditions which increase the serum calcium level in addition to the hyperparathyroidism with a complete breakdown of the calcium homeostasis, e. g. malignant tumors, primary and tertiary hyperparathyroidism, vitamin D poisoning or overdoses of calcium, vitamin D and calcium-containing ionizer in patients with renal insufficiency., Methods: We present the clinical course of five patients with an acute hypercalcemic crisis and discuss the diagnostic procedure and the principles of surgical treatment with regard to the current literature., Results: A hypercalcemic crisis develops if the total serum calcium concentration is over 4 mmol/l and parathormone over 90 pmol/l. The resulting syndrome is manifested by nausea and vomiting, polyuria and consecutive dehydration and hypotonia culminating in lethargy, hallucinations and coma. Hypercalcemia is the single most important diagnostic finding., Conclusion: The emergency therapy predominantly consists on the one hand in rehydration and parallel stimulation of diuresis. Urgent surgery is required if conservative therapy is not successful.

In 1700, the French surgeon Alexandre de Littré described for the first time a new form of inguinal hernia. This hernia varied from the known forms of hernias in its clinical course and in the postmortem examination results performed by Littrè himself. The characteristic feature of this hernia was the fact that the entire circumference of the bowel wall was not part of the hernial sac, but only the antimesenteric part of the intestinal wall. The underlying pathomechanism was explained 100 years later by Meckel. In a scientific paper about hernias some years earlier, Richter described the intestinal wall hernia, and this initiated the confusing use of the clinical entity known as the Richter-Littré hernia in Germany. In this case report we describe the historic development of this entity.

Gastric teratomas are rare and mostly benign. They frequently become evident as a palpable abdominal mass. A malignant, aggressive solid tumor must be excluded. We present a 6-month-old male infant with a history of bleeding of the upper gastrointestinal tract. After in toto excision the histopathology was that of a benign gastric teratoma. Our method of reading the diagnosis and the subsequent therapy are described.